Membership

APPLICATION FOR NIPA MEMBERSHIP
Applicant Full Name:
Company Name:
ABN (Australia only):

Postal Address
Line 1:
Line 2:
Suburb:
State:
Country:
Post/Zip Code:

Delivery Address
Line 1:
Line 2:
Suburb:
State:
Country:
Post/Zip Code:

Telephone Private:
Telephone Business:
Telephone Mobile:
Fax:
E-mail Address:
Web Site:

Business Information
Partners Name 1:
Partners Name 2:
Partners Name 3:

Business Commenced:	(dd.mm.yyyy)
Current Turnover:
Previous Year Turnover:

Main type of work undertaken (Mark with an X)
Design:	Service:
Hire:	Supply:
Product Sales:	Other:

Geographic area of work (Mark with an X)
Queensland:	Tasmania:
Victoria:	A.C.T.:
Western Australia:	New South Wales:
South Australia:	Northern Territory:
Other Country:

Years of experience in the industry
Company:
Self:

Qualifications
Tertiary:
Technical/Trade:

Q.A. Policy:
Public Liability Policy Num:
Workers Comp. Policy Number:

Staff Total:
Trainees:
Membership Fees are to be paid in full before an application will be processed.
NIPA reserves the right to refuse membership at the discretion of the Executive and Membership Committee.
I have read and agree to be bound by the Memorandum and Articles and Rules of the Constitution and By-laws made there under.
Signed :
Dated :	(dd.mm.yyyy)

Method of Payment:		(CC- Credit Card, DD-Direct Debit, CH-Cheque)
Please post or email any company brochures and business promotional literature to: National Interior Plantscape Association The Secretary PO Box 538 BURPENGARY Qld 4505 Australia.